CIHM 
Microfiche 
Series 
(Monograplis) 


ICMH 

Collection  de 
microfiches 
(monographles) 


lull 


Canadian  Inatltuta  for  Hbtorical  MIcroraproductions  /  Institut  Canadian  da  micforaproductians  hiatoriquaa 


1995 


Technical  and  Bibliographic  Notes  /  Notes  technique  et  bibliographiques 


The  Institute  has  attempted  to  obtain  the  best  original 
copy  available  (or  filming.  Features  of  this  copy  which 
may  be  bibllographically  unique,  which  may  alter  any  of 
the  images  in  the  reproduction,  or  which  may 
significantly  change  the  usual  method  of  filming  are 
checked  below. 

Vy\      Coloured  covers  / 
' — '     Couverture  de  couleur 

I     I      Covers  damaged  / 

' — '     Couverture  endommagte 

I     I      Covers  restored  and/or  laminated  / 
' — '     Couverture  restaur^  et/ou  pellicula 

r~]     Cover  title  missing /Letitrede  couverture  manque 

I     I     Coloured  maps  /  Cartes  gtegraphiques  en  couleur 

I     I      Cotoured  ink  (i.e.  other  than  blue  or  black)/ 

Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire) 

I     I      Coloured  plates  and/or  iHustratrons/ 
' — '      Planches  et/ou  illustratk>ns  en  couleur 

I     I      Bound  with  other  material  / 
' — '      Reli*  avec  d'autres  documents 

□     Only  editx>n  available/ 
Seule  Mition  dtsponible 

r~|  Tight  binding  may  cause  shadows  or  distortion 
along  interior  margin  /  La  reliure  serria  peut 
causer  de  I'ombre  ou  de  la  distarsnn  le  long  de 
la  marge  int6rieur». 

I  I  Blank  leaves  added  during  restoratkxis  may  appear 
' — '  within  the  text.  Whenever  possible,  these  have 
been  amMed  from  flming  /  II  se  peul  que  certaines 
pages  blanches  ajouties  k>rs  d'une  restauratkm 
apparaissent  dans  le  tsxte,  mais,  kirsque  cela  Malt 
poGsUe,  ces  pages  n'ont  pas  M  Nm«». 


I     I      AddMonei  comments/ 

' — '      Commentaires  si^iplementaires: 


L'Institut  a  microfilm^  le  meilleur  examplaire  qu'il  lui  a 
M6  possible  de  se  procurer  Les  details  de  cet  exem- 
plaire  qui  sent  peut-6trB  uniques  du  point  de  vue  bibli- 
ographkjue,  qui  peuvent  modifier  une  image  reproduite, 
ou  qui  peuvent  exiger  une  modifications  dans  la  mdth- 
ode  normale  de  filmage  sont  indk^u^s  ci-dessous. 

I     I     Cokxired  pages/ Pages  de  couleur 

I     I      Pages  damaged/ Pages  endommagies 

I     I      Pages  restored  an*or  laminated  / 
— '      Pages  restaurtes  et/ou  pellicultes 

rT'    Pages  discoloured,  stained  or  foxed  / 
— '      Pages  d«cok>r«es,tachet«esoupiqu«es 

I     I      Pages  detached/ Pages  d4tach«es 

[^     Showlhrough/ Transparence 

I     I     Quality  of  print  varies  / 

' — '     Quality  inigale  de  I'lmprssskHi 

r~|      Includes  supplementary  material  / 
—      Comprend  du  materiel  suppWmentaJre 

I  I  Pages  wholly  or  partially  obscured  by  errata 
— '  slips,  tissues,  etc.,  have  been  returned  to 
ensure  the  best  possible  Image  /  Les  pages 
totalement  ou  partisllement  obscurcies  par  un 
feuillet  d'errata,  une  pelure,  etc.,  ont  Mi  filmtes 
i  nouveau  de  fa(on  k  obtenir  la  meilleure 
image  possible. 

[  I  Opposing  pages  with  varying  colouration  or 
' — '  discolourations  are  filmed  twne  to  ensure  the 
best  possible  image  /  Les  pages  s'opposant 
ayant  des  colorations  varialHes  ou  des  dteol- 
orations  sont  film<es  deux  fois  afin  d'obtenir  la 
meilleur  image  possible. 


Thiitl 
C*do 

10X 

cunrn 

filma 
itnt 

d<t« 
filmi 

he  red 
■u  Ml 

14X 

18X 

22X 

ax 

KX 

J 

1 

12X 

1CX 

20X 

24  X 

2«X 

32X 

Th«  copy  filmad  hara  haa  baan  rapreduead  thanks 
to  iha  ganarosity  of: 

National  Library  of  Cfuiada 


L'axamplaira  iUmt  ful  raproduit  griea  t  la 
g*n*roait«  da: 

Bibliothiqua  nationala  du  Canada 


Tha  imagaa  appaaring  hara  ara  tha  baat  quality 
poaaibia  eonaidaring  tha  condition  and  laglbillty 
of  tha  original  copy  and  in  kaaping  with  tha 
filming  contract  spacificatiana. 


Original  capias  in  printed  papsr  covsrs  sra  fllmad 
beginning  with  tha  front  cover  and  ending  on 
the  last  page  with  a  printed  or  illuatratad  impree- 
sion,  or  tha  bacli  cover  when  appropriate.  Ail 
other  original  copies  ara  filmed  beginning  on  tha 
first  page  with  a  printed  or  illustrated  impree- 
aion,  and  ending  on  the  laat  page  with  a  printed 
or  Uiuetraiad  impression. 


Les  images  suivantas  ent  *t*  raproduitas  avsc  is 
plus  grand  soin,  compte  tenu  de  la  condition  et 
do  is  nattet*  da  i'asemplaira  film*,  at  an 
eonf  ormit4  evec  lea  conditions  du  contrst  de 
fllmaga. 

Lee  esempiairee  originaus  dont  la  couverture  en 
papier  eat  ImprimSe  sent  fiimSs  en  eommencant 
par  le  premier  plet  et  en  terminani  soit  par  la 
darnMre  page  qui  comperte  une  emprainta 
d'imprasaion  ou  d'illuatration,  soit  par  la  second 
plat,  salon  le  eas.  Toua  lea  autras  axemplairas 
originaux  sont  fiimts  en  commencant  par  la 
pramitre  page  qui  eomporte  une  empreinte 
d'Impreaaion  ou  d'lilustrstion  at  en  terminant  par 
la  dernMre  page  qui  eomporte  une  telle 
empreinte. 


The  laat  recorded  freme  on  eech  microfiche 
shell  contain  tha  symbol  •^  (meaning  "CON- 
TINUED"), or  the  symbol  ▼  (meaning  "END"), 
whichever  appliea. 


Un  dee  symboles  suivants  spparattra  sur  la 
darniire  Image  de  cheque  microfiche,  selon  le 
cas:  la  symbols  -»■  signifie  "A  SUIVRE".  le 
symbols  ▼  signifie  "FIN". 


Mapa,  pistes,  charu,  etc.,  may  be  filmed  at 
different  reduction  ratios.  Those  toe  large  to  be 
entirely  included  in  one  expoaura  ara  filmed 
iMginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bonom.  as  many  frames  aa 
required.  The  following  diagrama  Illustrate  the 
method: 


Lea  cartes,  planches,  tableaux,  etc.,  peuvent  strs 
filmto  i  des  taux  de  rSduction  diffSrents. 
Lorsqus  le  document  est  trop  grand  pour  itre 
reproduit  en  un  seui  cliche,  il  est  filmA  *  partir 
de  Tangle  supArisur  gauche,  de  gauche  t  dreite. 
et  de  haut  an  bas,  an  prenent  le  nombre 
d'imeges  nicsssaira.  Lea  diagrammes  suivsnts 
lilustrsnt  la  mSthoda. 


1  2  3 


1 

2 

3 

4 

5 

6 

*'»CtOCOPr   HSOtUTION   TBT  CHART 

(ANSt  ond  rSO  TEST  CHART  No.  2) 


^  >^PPLIED    IM/1GE      In 

^R  1653  Zatt  Main  Straal 

SS  "*=•!•■»■'.   "•■  York        14509       USA 

^S  (716)  482  -  0300  -  ■"'hone 

BB  (^16)  ZSe-59S9  -Fax 


SOMF.   KURMlTv-W  CLINICS, 


R.  J.   MAxroN,    M.D..    L.R.C.P.&S. 

(EniNj.  L.F.F-&S.    ((iLASc.nw), 

roRT    WILLIAM,    UNT. 


Reprinted  from  tht 

New  York  Medical  Journal 

INCORPURATIKr.   THt 

Philadelphia  Medical  Journal  and 
The  Medical  News. 

.'icptciulh-r  -'A,    ;<j/4. 


Reprinlti  from  ihe  New  York  Medical  Journal  for 
September  16,  ivi^. 


SOME  EUROPEAN  CLINICS.* 

By  R.  J.  Manion,  M.  D.,  L.  R.  C.  P.  &  S.  (Edin.), 

L.  F.  P.  &S.  (  Glasgow  ), 

Fort  Wmiam,  Ont. 

The  following  paper  was  written  from  a  few 

notes  made  during  a  three  months'  Europeaii  trip  in 

the  early  part  of  1914,  and  the  v>friter  apologizes  for 

its  brevity,  offering  in  excuse  the  fact  that  his  was 

primarily  a  pleasure  trip,  and  attendance  at  clinics 

was  only  a  side  issue.    These  few  facts  are  written 

with  the  hope  that  they  may  be  of  interest  to  some 

of  my  fellow  practitioners. 

LONDON. 

In  this  immense  city  with  its  numerous  fine  hos-_ 
pitals,  the  ordinary  tourist  is  handicapped  by  the 
fact  that  most  of  the  surgical  clinics  are  held  in  the 
afternoon,  for  most  of  us  prefer  to  work  in  the 
morning  and  holiday  after  lunch.  At  Guy's  I'os- 
pital  one  may  usually  count  upon  seeing  work  any 
afternoon.  The  great  drawing  card  at  this  hospital 
to  the  visiting  surgeon  is  that  surgical  superman, 
Sir  W.  Arbuthnot  Lane,  whose  never  failing  cour- 
tesy and  kindness  cannot  be  forgotten  by  any  one 
who  has  had  the  pleasure  and  privilege  of  seerag 
him  at  work.  His  short  circuiting  bowel  operations 
and  his  bone  work  are  his  most  interesting  pro- 
cedures. He  short  circuits  in  cases  showing  the 
earmarks  of  intestinal  stasis ;  for  instance,  one  case 
was  that  of  a  woman  aged  thirty-two  years,  consti- 
pated, nervous,  and  with  marked  staining  of  the 
skin.  If  the  colon  sags  markedly,  instead  of  doing 
the  short  circuiting  operation,  he  removes  the  colon. 
In  "hronic  ulcer  of  the  stomach,  he  also  does  one 

•Read  before  the  Thunder  Biy,  Ont..  Medical   Society.  June    ii. 


1914. 


Copyright,  1914,  by  A.  K.  Elliott  Publllhirc  Company. 


fh35 


Manion:  Some  Europtan  Clinict. 

of  these  operations,  following  it  by  liquid  paraffin 
treatment.  Of  the  liquid  paraffin  treatment  he 
speaks  highly  in  gastric  ulcer  cases  and  in  chronic 
constipation,  makmg  the  statement  to  the  writer 
that  many  cases  of  ulcer  of  the  stomach  may  be 
cure<',  temporarily  at  least,  by  rest  and  liquid 
paraffin.  One  woman  operated  upon  in  the  presence 
of  the  writer,  had  first  been  operated  upon  by  Mr. 
Lane  eight  years  before  for  appendicitis,  which 
operation  relieved  her  for  three  years.  Then,  her 
symptoms  returning,  he  did  a  short  circuiting  opera- 
tion with  a  side  to  side  anastomosis  betweefl  ileum 
and  sigmoid,  giving  her  good  health  for  another 
three  years.  Again  she  complained  of  pain  in  the 
abdomen.  He  opened  the  abdomen  and  found  that 
at  the  ileosigmoid  junction  the  ileum  had  kinked, 
causing  obstruction.  He  relieved  the  kink  and 
sewed  the  mesentery  in  such  a  way  as  to  prevent  a 
recurrence  of  the  obstruction.  He  stated  that  now 
in  all  cases  he  does  a  side  to  side  anastomosis,  and 
always  stitches  the  mesentery  of  the  ileum  in  place 
to  prevent  sagging.  His  bone  work  needs  no  praise 
from  me,  but  it  is  marvelous  to  watch  him  opien  up 
fractures,  replace  fragments,  plate  them,  and  close 
up  the  wounds  with  great  rapidity,  at  the  same  time 
appearing  to  be  in  no  hurry,  without  once  putting 
his  gloved  finger  in  the  wound.  To  use  his  own 
words,  he  "always  operates  on  fractures  of  all  kinds, 
and  at  once,  as  there  is  no  danger."  This  is  no 
doubt  true  for  him,  but  not  for  all  of  us.  In  one 
case  of  a  T  shaped  fracture  of  the  ptella,  he  made 
a  straight  incision,  protected  the  edges  with  gauze, 
coapted  the  three  fragments  with  his  own  forceps, 
put  in  two  plates,  fixinj;  both  lower  fragments  to 
the  upper,  and  closed  the  wound  with  clips,  the 
whole  taking  fifteen  minutes,  and  nothing  had  been 
in  the  wound  except  his  frequently  sterilized  instru- 
ments. The  small  amount  of  bleeding  he  ignored, 
for  as  a  principle  he  tries  to  leave  no  catgut  or  other 
ligature  material  in  the  wound.  It  is  beautiful  work 
as  he,  does  it.    On  being  questioned  as  to  the  per- 


ManioK:  Snmf  Huroffaii  CImiet. 

ccntage  of  plates  later  re-noved,  he  stated  that  he 
removed  none.  At  oni.  the  clinics  he  demon- 
strated on  the  skin  of  ou.  arms  that  his  stomach 
and  bowel  clamps,  whitn  have  concavo-convex 
blades,  do  no  injury  to  the  tissues.  He  takes  great 
pleasure  in  arguing  points  with  his  visitors,  making 
even  the  youngest  feel  perfectly  at  home,  and  one 
just  naturally  leaves  his  clinic  beli-.ving  that  no 
more  masterful  surgeon  or  more  charming  man 
exists.  He  stated  that  he  was  looking  forward  with 
much  pleasure  to  the  Clinical  Congress  of  Surgeons 
in  July. 

In  the  same  (Guy'O  hospital  are  a  number  of 
other  fine  surgeons.  The  writer  saw  Mr.  Dunn  per- 
form a  very  able  operation  for  removal  of  a  car- 
cinomatous tongue  through  the  neck,  using  intra- 
tracheal anesthesia.  Another  afternoon  the  clinic 
of  Mr.  Fagge  was  attended.  One  case  was  that  of 
a  woman  which  was  diagnosed  simply  as  "abdominal 
pain,"  but  in  which  he  removed  an  adherent  ap- 
pendix and  gallstones,  and  relieved  a  kink  at  the 
cecum.  One  interesting  statement  made  by  Mr. 
Fagge  was  that  "while  hematemesis  is  suggestive  of 
gastric  ulcer,  it  is  no  proof,  for  it  may  be  found 
when  the  only  lesion  is  appendicitis."  Mr.  Belling- 
ham  Smith  was,  like  the  others  mentioned,  most 
kindly,  and  he  is  well  worth  witnessing  at  his  gyne- 
cological operations,  which  he  performs  with  ad- 
mirable deftnesj  and  rapidity.  All  of  these  men  are 
aseptic  in  their  technic,  and  visitors,  who  are  al- 
lowed on  the  floor,  wear  gowr.j,  caps,  and  masks, 
and  wash  their  hands  before  entering  the  operating 
room.  Drop  method  ether  is  used  a  good  deal. 
Guy's  buildings  ar  old  looking,  but  tie  operating 
department  is  new,  clean,  and  aseptic. 

St.  Thomas's  Hospital  is  a  fine  colleclion  of  '.  lild- 
ings ;  the  entrance  is  decorated  with  marble  busts  of 
past  maiiters.  Here  the  writer  saw  Mr.  Marriage 
perform  a  mastoid  operation,  which  was  as  interest- 
ing as  this  operation  usually  is  to  the  general  sur- 
geon.    The  anesthetic  was  chloroform  and  ether, 


Vom'iiii.  Some  European  CVimVi. 

followed  by  nitrogen.  An  interesting  case  operated 
in  by  Mr.  Battle  was  that  of  a  man  who  had  had 
dysentery  in  the  tropics,  and  now  complained  of  pain 
in  the  right  chest  accompanied  by  expectoration  of 
fifteen  or  sixteen  ounces  a  day  of  foul  matter.  The 
diagnosis  was  abscess  of  the  lung.  Intratracheal 
anesthesia  was  used  and  an  incision  was  made  in  the 
axilla,  removing  two  inches  of  rib.  The  abscess  was 
found  three  inches  from  the  surface  of  the  lung,  and 
a  tube  inserted.  The  technic  at  this  hospital  is  ex- 
cellent, all  the  up  to  date  accessories  being  em- 
ployed, and  this  is  roughly  trne  of  most  of  the 
European  clinics.  In  this  re^rd  one  might  easily 
imagine  oneself  in  an  operatmg  room  in  Chicago, 
New  York,  Toronto,  or  Fort  William. 

A  pofitable  afternoon  was  spent  at  Middlesex 
Hospitjl,  watching  the  work  of  Sir  John  Bland 
Sutton,  whom  the  writer  had  the  pleasure  of  seeing 
at  Chelsea  Hospital  ten  years  ago.  He  did  not,  in 
1914,  appear  any  older  or  any  less  the  surgeon  than 
in  1904.  Sir  John  was,  as  is  the  custom  with  all  the 
London  surgeons,  late.  If  any  of  them  ever  come  at 
the  time  called  for  the  operations,  the  writer  failed 
to  discover  it.  Sir  John  quickly  and  beautifully  re- 
moved a  strangulated  parovarian  cyst.  His  closure  of 
the  abdomen  was  as  follows :  i.  Through  and  through 
linen,  not  tied ;  2,  interrupted  linen  in  peritoneum, 
tied;  3,  tied  through  and  through  sutures;  4,  con- 
tinuous linen  in  skin.  This  made  a  veijr  pretty 
closure.  Another  case  at  his  clinic  was  that  of  a 
woman  who  had  been  sent  into  the  hospital  for  the 
removal  of  a  fibroid  of  the  uterus,  and  whom  he  was 
to  examine  under  ether.  On  examination  no  fibroid 
was  found,  but  he  said  that  it  was  a  case  of  tumor 
of  the  bUdder.  Hematuria  prevented  him  using  the 
cystoscope  satisfactorily,  so  he  dilated  the  urethra 
with  graduated  dilators  and  inserted  his  finger  into 
the  bladder,  finding  an  egg  sized  polypus.  He  re- 
marked that  some  objected  to  this  method  of  ex- 
amination, but  "I  have  been  doing  it  for  five  and 
twenty  years    -ithout  injuring  a  patient."     As  he 


MdMion:  Some  liurofcan  Clinics. 

had  not  the  patient's  consent  for  an  operation  on  the 
bladder,  he  said  that  he  would  have  to  obtain  it  and 
then  he  would  go  in  suprapubically.  In  his  clinic 
no  caps  or  masks  were  used  bv  himself  or  assistants, 
the  "sisters"  wearing  caps.  In  all  the  London  hos- 
pitals, iodine  is  largely  used.  An  amusing  thing  m 
most  of  these  hospitals  is  the  small  pot  de  chambrt 
shape  cf  the  pus  basins. 

DUBLIN. 

In  the  Irish  metropolis  two  hospitals  were  visited, 
but  unfortunately  no  operations  were  on  at  the 
time.  The  far  famed  Rotunda  was  gone  over,  in 
company  with  a  courteous  house  surgeon,  w'lo 
showed  the  massive  building  with  its  fine  opcratmg 
room,  delivery  room,  good  laborat  ries,  and  large, 
airy,  clean  wards.  The  hospital  is  >  msectarian,  and 
is  in  charge  of  Doctor  Jellett,  whc  .cceeded  Doctor 
Tweedy,  whose  writings  are  widely  read.  They 
have  very  little  sepsis  after  labor,  and  *hei.-  treat- 
ment is  an  intrauterine  douche,  perhaps  only  0"e, 
followed  by  autogenous  vaccines  prepared  in  t' 
own  laboratories.  In  front  of  the  hospital  is  a  pi;' 
erected  in  honor  of  F'arnell,  that  stout  Home  Ruicr, 
on  the  base  of  the  pillar  being  the  following  quota- 
tion from  one  of  his  speeches  which  seems  apropos 
during  the  Irish  troubles  of  today :  "No  man  has  a 
right  to  fix  the  boundary  of  the  march  of  a  nation. 
No  man  has  a  right  to  say  to  his  country,  'thus  far 
shalt  thou  go  and  no  further.'  We  have  never  at- 
tempted to  fix  the  ne  p'us  ultra  to  the  progress  of 
Ireland's  nationhood  and  we  never  shall." 


There  are  many  good  clinics  in  Paris,  but  they 
are  not  much  attended  by  Americans  or  Canadians, 
except  French  Canadians  whose  knowledge  of  the 
French  language  is  an  open  sesame  to  them.  The 
Paris  surgeon's  native  courtesy  makes  him  welcome 
the  visitor  royally,  but  generally  speaking,  to  get 
the   best    from   the   clinic   one   must   know    some 


Manioii:  Some  European  Ctinici. 


French.  During  a  fairly  lengthy  stay  in  Paris  only 
two  prominent  clinics  were  visited,  in  addition  to  a 
morning  spent  at  the  Pasteur  Institute.  At  the 
Hotel  Dieu,  that  oldest  of  the  hospitals  of  Paris, 
Doctor  Potherat,  chief  of  the  service,  a  surgeon  of 
the  old  school,  welcomed  the  writer,  regretting  his 
inability  to  speak  English.  The  writer's  rather 
limited  knowledge  of  French,  by  the  way,  was  of 
much  service,  not  only  in  France,  but  throughout 
Europe.  The  technic  here  was  excellent,  the  sur- 
geon and  assistants  (wearing  gown,  cap,  and  ma^k, 
and  all,  except  the  surgeon,  rubber  gloves.  The  ab- 
dominal cases  were  prepared  with  alcohol  and 
iodine.  The  operator  worked  quickly  and  showed 
rapid  judgment  in  a  diffiiMlt  case  of  fistula  after  an 
abdominal  abscess,  using  a  rectus  incision  to  open 
the  abdomen.  The  wound  was  closed  with  continu- 
ous catgut  and  clips.  One  old  fashioned  instrument 
was  used  by  this  handsome  old  surgeon,  in  the  form 
of  a  pointed  hook  which  he  thrust  through  the 
tissues,  threaded,  and  withdrew,  doing  this  as 
rapidly  as  another  could  use  a  needle.  Despite  the 
age  of  the  Hotel  Dieu,  the  operating  rooms  are 
quite  modem.  In  the  quadrangle  are  a  number  of 
monuments,  among  them  one  "to  their  dead  com- 
rades, victims  of  their  devotion  during  their  in- 
ternships in  medicine  in  the  hospitals  of  Paris  from 
1802  to  1902." 

Doctor  Doyen's  clinic  is  one  of  the  most  popular 
in  Paris.  His  private  hospital  is  an  immense  and 
elaborate  institution  in  the  rue  Piccini  just  off  that 
most  beautiful  promenade,  the  avenue  du  Bois  de 
Boulogne.  No  sign  or  mark  on  the  building  dis- 
tinguishes it  from  the  many  beautiful  private  man- 
sions in  the  neighborhood.  That  the  institution  is 
well  known  was  evidenced  by  the  unhesitating 
manner  in  which  the  chauffeur  of  a  hailed  taxicab 
landed  the  writer  at  Doctor  Doyen's  door,  with  that 
nerve  racking,  comer  skidding  rapidity  known  best 
to  the  Parisian  chauffeur.  Most  of  the  others 
present  were  French,  with  a  sprinkling  of  Austrians, 


Matiiou:  Some  European  Clitiict. 

one  of  whom  spoke  highly  of  this  clinic.    The  wait- 
ing rooms  and  studies  are  decorated  with  busts  and 
paintings,  and  contain  books.    On  one  of  the  walls 
of  the  operating  room  is  a  large  crucifix,  no  doubt 
to  inspire  faith  and  hope  in  the  minds  of  the  pa- 
tients, and  perhaps  for  the  same  pious  reasons  which 
caused  a  great  man  like  Pasteur  to  be  religious  in 
the  highest  sense.    Doctor  Doyen,  who  has  the  ap- 
pearance of  a  good  natured,  well  to  do,  comfortable 
farmer,  showed  us  perhaps  a  dozen  cases  of  cancer 
in  which  he  had  operated  in  the  past  seven  years, 
some  of  them  quite  recently,  by  excision  followed 
by  what  he  called  electrocoagulation.     They  were 
good  results,  but  some  showed  large  defects  in  the 
area  of  the  previous  cancer.    He  seems  very  well 
satisfied  with  his  own  results.     He  operated  in  a 
number  of  cases  by  this  method,  one  being  exceed- 
ingly striking.     It  was  that  of  a  large  carcmoma 
involving  the  right  ear  and  surrounding  tissue,  mak- 
ing a  swelling  the  size  of  a  fist.    He  first  exposed 
quickly  the  carotid,  probably  to  be  ready  to  tie  it  if 
necessary.     Then  he  made  an  incision  completely 
surrounding  the  tumor  and  the  ear,  removing  both 
very  rapidlv.    In  dissecting  away  some  glands,  he 
cut  a  piece' out  of  the  side  of  a  vein,  immediately 
stitching  the  vein  with  fine  silk.    After  tying  the 
necessarv  vessels,  which  were  very  few  considering 
the  magnitude  of  the  operation,  he  curetted  the  sur- 
face, then  used  the  electricity,  thoroughly  cooking 
the  surface  into  a  dry  eschar,  and  finally  covered 
the  wound  with  a  dry  powder  dressing.    It  was  a 
beautiful  and  rapid  piece  of  work  in  a  hopeless  look- 
ing case.    After  his  operations,  he  demonstrated  on 
a  piece  of  raw  beef  the  effects  of  varying  currents 
of  electricity  with  different  electrodes,  showing  well 
his  power  to  have  whatever  effect  he  wished,  and 
convincing  one  of  the  value  of  electricity  used  prop- 
erly in  these  cases.     The  spectators  wore  gowns, 
and  in  addition  there  was  a  glass  screen  between  the 
operation  and  the  visitors.    Doctor  Doyen  at  times 
loses  his  temper  with  his  assistants  in  true  Latin 


Manion:  Some  European  Ctinicj. 


fashion,  but  in  this  he  cannot  equal  some  Italian 
surgeons,  who  appear  at  times  on  the  verge  of 
physically  maltreating  their  assistants. 

The  Pasteur  Institute  in  the  rue  Dutot  is  worthy 
of  a  visit.  The  whole  neighborhood  is  named  after 
Pasteur,  and  in  addition  m  another  section  of  the 
city  is  a  monument  in  his  honor.  Paris  is  as- 
suredly one  of  the  cities  which  honor  their  scientists. 
In  front  of  the  institute  is  the  Gtatue  of  a  boy  fight- 
ing with  a  wolf,  probably  representing  Uttle  Meister 
or  little  Jupille,  his  first  two  patients  for  the  pre- 
vention of  hydrophobia.  Inside  the  institute  are 
the  usual  features  of  a  research  laboratory,  rabbits, 
mice,  guineapigs,  and  smells,  but  most  important 
are  the  earnest  workers  ia  their  laboratories.  They 
treat  here  fifteen  or  twenty  patients  daily  for  the  pre- 
vention of  hydrophobia,  and  as  I  came  out  a  pair 
of  anxious  parents  with  a  frightened  child  rushed 
in  to  participate  in  the  gift  that  Pasteur  gave  to  the 
world.  All  about,  one  recognizes  the  veneration  in 
which  the  master  was  held.  Near  the  entrance  to 
his  tomb,  which  is  in  the  building,  are  two  silver 
wreaths,  one  "from  the  Institut  de  Pasteur  to  its 
chief,"  and  the  other  "to  Pasteur  from  the  students 
of  France."  The  sarcophagus  is  exceedingly  beauti- 
ful, and  is  in  a  crypt  of  marble  and  varicolored 
mosaic.  The  tomb  was  built  by  his  children,  and 
contains  also  the  body  of  his  loving  and  loved  wife. 
Worked  into  the  mosaic  are  the  following:  "Faith, 
Hope,  Charity,  Science";  and  on  the  other  side, 
"Blessed  is  he  who  carries  in  himself  an  ideal  of 
beauty,  and  who  obeys  it,  an  ideal  of  art,  an  ideal 
of  science,  an  ideal  of  patriotism,  an  ideal  of  the 
virtues  of  the  Gospel."  The  institute  is  at  present 
in  charge  of  Doctor  Metchnikoff  and  Doctor  Roux. 


This  beautifully  picturesque  Swiss  city  is  the 
home  of  Dr.  Theodor  Kocher  and  his  son.  From 
the  hotel  or.e  sends  a  card  with  a  request  to  attend 
the    operations,    and    the    following   day    Doctor 


1 


Manioti-  Some  European  Ctmict. 

Kocher  has  a  message  telephoned  to  let  one  know 
the  hour  and  the  place  to  attend.  At  the  hospital 
the  visiting  surgeon  is  given  every  welcome.  Both 
father  and  son  speak  English.  The  writer  saw  both 
operate  at  the  Insel  Spital.  The  details  are  ex- 
cellent, gowns,  caps,  masks,  and  gloves  being  em- 
ployed, the  assistants  wearing  cotton  gloves  over  the 
rubber  ones.  Most  goitre  operations  are  done  under 
local  anesthesia,  novocaine  one  per  cent,  with  adren- 
aline; the  line  of  incision  only  is  injected,  yet  no 
complaints  come  from  the  patients  during  the  opera- 
tion. Many  forceps  are  used,  arresting  all  bleeding 
as  the  operation  proceeds ;  generally  slow  and  care- 
ful work  is  done.  To  children  and  nervous  patients 
ether  is  given  with  a  modified  Clover  inhaler,  which 
is  also  used  in  other  operations.  Both  father  and 
son  operate  in  the  same  room  at  the  same  time,  and 
a  spectator  can  watch  the  two  operations,  if  he  does 
not  wish  to  see  too  many  details.  Dr.  Theodor 
Kocher  is  a  small  old  man  with  a  pleasant,  smiling 
face,  which  gives  a  hearty  welcome  to  the  visitor. 


1 

4 


In  this  romantic  old  city  of  the  Caesars  and  the 
Popes,  one  very  entertaining  morning  was  spent  at- 
tending the  operations  of  i-iofessor  Bastianelli  at 
the  Policlinico  Umberto,  a  fine,  large,  two  storied 
building,  erected  in  1893.  Professor  Bastianelli, 
who  speaks  English  fluently,  and  whose  kindness  is 
unbounded,  has  a  large  service,  doing  many  opera- 
tions three  mornings  a  week — Tuesday,  Thursday, 
and  Saturday.  Iodine  preparation  is  used  exten- 
sively in  this  clinic,  as  is  also  ether  by  the  drop 
method,  although  occasionally  chloroform  is  used. 
The  operating  table  is  that  of  Janetti,  of  Turin.  It 
stands  on  a  central  pivot  and  can  be  put  into  any 
position.  Professor  Bastianelli  spoke  highly  of 
some  of  the  American  surgeons,  particularly  of 
Murphy,  whose  joint  work  he  lauded  enthusias- 
tically. Among  the  cases  operated  in  was  one  of 
ulcerating  tu'jerculous  glands  in  ttie  neck.    He  dis- 


Manion:  Some  European  Ctmies. 

sected  them  out,  and  sewed  up  the  wound  tightly, 
using  catgut  and  silk.     He  stated  that  he  rarely, 
pert^ps   twice   yearly,   operated    for   tuberculous 
elands      He  does  not  use  tuberculin,  but  injects 
about  the  affected  glands  iodine  solution,  one  per 
cent    with  potassium  iodide,  two  per  cent.    He  says 
that  "this  is  an  excellent  remedy,  as  it  takes  about 
two  years  to  effect  a  cure,  and  in  Italy  with  its 
warm    sun   and    the    Mediterranean,    tuberculous 
elands  get  better  m  that  time  anyway."    Another 
case  was  one  of  gangrene  of  the  skin,  caused  by  the 
previous  surgeon  thinking  that  he  had  a  case  of 
broken  arm.  and  putting  the  arm  in  a  plaster  ot 
Paris  bandage,  the  swelling  causing  an  ischemic 
paralysis  and  sloughing  of  the  skin  at  the  elbovf. 
Then  the  arm  was  allowed  to  heal  m  a  flexed  i»si- 
tion      Doctor  Bastianelli  had  previously  remedied 
this  by  a  large  flap  from  the  belly  wall,  and  he  was 
now  completing  the  separation  of  th^   skin.     Ihe 
man  could  ateiost  completely  straighten  the  arm, 
giving  a  fine  result.     The  professor  showed  us  a 
number  of  other  cases  of  skin  grafting  by  the  same 
method. 

FLORENCE. 

Two  mornings  were  spent  at  the  old  Santa  Maria 
Nuovo.  The  arcaded  front  of  the  building  is  dec- 
orated with  many  old  frescoes,  very  artistically 
done,  but  one  of  them,  namely,  the  Slaughter  of 
the  Innocents,  1  thought  slightly  inappropriate  for 
the  front  of  a  hospital,  and  especially  did  1.  think 
this  when,  on  entering  this  2,000  bed  hospital,  1 
saw  the  good  work  done.  The  time  was  most  pleas- 
antly spent  with  Professor  Machiti,  who  spoke  no 
English,  but  spoke  French  fluently.  No  one  coula 
be  more  courteous  than  he.  Among  other  opera- 
tions, he  did  three  hernias  by  the  Bassini  method, 
which,  he  told  the  writer,  he  found  the  most  satis- 
factory, under  novocaine  lumbar  anesthesia.  He 
uses  this  form  of  anesthesia  entirely  in  operations 
below  the  nipple  line,  and  has  had  no  complications, 
•'jamais,  jamaisf    He  never  uses  any  other  suture 


ManioH:  Some  European  Clinics. 


material  but  silk,  and  in  the  three  operations  he  tied 
only  one  vessel.  For  most  bleeders  he  grasps  the 
base  of  the  vessel  and  fat  virith  an  angioclast  re- 
sembling a  curved  artery  forceps,  and  twists  the  tip 
of  this  mass.  He  is  careful  to  get  a  dry  wound,  and 
he  has  had  only  two  per  cent,  of  recurrences:  In 
this  clinic  gowns,  cap,  and  thick  rubber  gloves  are 
used.  The  operator's  hands  are  prepared  with  soap, 
sterile  water,  and  ether,  and  the  patient  with  six  per 
cent,  iodine.  The  gowns,  caps,  and  gloves  were  not 
changed  between  operations.  The  operating  room 
was  old  but  good,  but  the  amount  of  water  that  is 
thrown  carelessly  about  in  some  of  these  operating 
rooms  is  appalling  to  an  American  or  a  Cana- 
dian. At  times  one  almost  fears  having  to  swim 
to  safety.  Under  spinal  anesthesia  the  patients  did 
not  experience  any  discomfort,  though  his  manipu- 
lations were  no  gentler  than  they  would  be  under 
general  anesthesia,  but,  he  says,  it  occasionally 
causes  temporary  paralysis  of  the  sphincter  ani. 
The  patients  recover  from  its  effects  in  one  or  two 
hours.  Professor  Machiti  used  no  needle  holder, 
even  when  working  in  fatty  depths,  and  he  did  his 
work  rapidly  and  accurately.  In  fact  the  needle 
holder  is  not  much  used  in  Europe  outside  of 
Vienna. 

VIENNA. 

In  this  great  centre  one  can  see  many  operations, 
but  a  large  percentage  of  them  are  done  by  assistants 
or  by  the  assistants  of  the  assistant.  In  von  Eisels- 
berg's  clinic  during  four  or  five  days'  attendance, 
von  Eiselsberg  was  seen  only  once.  The  technic  is 
the  same  as  that  seen  at  Chicago,  or  Rochester,  or 
New  York.  Goitre  is  usually  done  under  local  an- 
esthesia, using  the  patient's  voice  to  protect  the  re- 
current nerve.  The  sitting  up  position  for  opera- 
tions on  the  head  and  neck  is  also  much  employed. 
Iodine  is  much  in  evidence  in  the  preparation  of 
patients,  and  the  ether  drop  method  is  used.  The 
warmth  of  patients  during  operations  is  apparentW 
not  considered  essential.  The  spectators  are  gowneu, 


Mjnion:  Some  European  Clinics. 

and  are  expected  to  keep  absolute  silence.  Michel's 
clips  are  used  for  the  skin.  The  operations  by  the 
young  surgeons  are  naturally  slow,  and  diagnosis  is 
not  any  more  perfect  than  one  might  expect.  In 
one  case  a  child  had  portions  of  two  ribs  removed 
for  an  empyema  which  did  not  exist,  or,  at  least, 
was  not  found.  These  young  operators  are  neither 
better  nor  worse  than  other  young  surgeons.  The 
right  rectus  incision  is  used  in  appendix  cases. 

The  writer  did  not  have  the  good  fortune  to  see 
any  work  in  Hochnegg's  clinic,  and  after  only 
eight  days  spent  in  Vienna  does  not  think  that  criti- 
cisms would  be  fair,  but  from  the  surgical  work 
witnessed  he  dees  not  tHink  that  there  is  any  neces- 
sity for  a  young  surgeon  \q  leave  the  American  con- 
tinent to  see  good  surgery.  The  American  Associa- 
tion of  Vienna  is  of  much  use  to  the  postgraduate 
student,  particularly  in  case  of  a  long  stay.  In 
talking  with  a  number  of  the  members  who  have 
spent  some  time  in  Vienna,  they  expressed  the  opin- 
ion that  the  surgerj-  there  is  not  at  all  extraordinary, 
in  fact  that  in  general  work  Vienna  is  much  over- 
rated, only  really  excelling  in  pathology,  eye  and 
ear  work,  and  in  x  ray  teaching.  The  pathology 
should  be  pspecially  good,  as  all  fatal  cases  must 
be  examined  post  mortem.  The  writer  spent  one 
morning  in  the  post  mortem  room  of  the  Kranken- 
haus,  and  saw  five  ai  lopsies,  and  he  understands 
that  there  are  daily  about  ihis  number.  On  leaving 
the  hospital  and  regaining  the  Ringstrasse,  one  may 
spend  a  few  elevating  moments  in  the  court  of  the 
immense  University  of  Vienna.  In  this  court  are 
innumerable  marble  busts  of  past  professors,  among 
them  those  of  Nothnagel,  Billroth,  Skoda,  and 
Krafft-Ebing.  As  one  saunters  about  the  court  and 
corridors  and  notes  the  groups  of  students,  some 
hurrving  to  their  work,  others  lounging  about,  care- 
less or  anxious  as  may  be,  one  is  wafted  back 
through  the  years  that  have  gone  to  those  happy, 
careless,  never  to  be  forgotten  (and  unfortunately, 
never  to  be  recalled)  student  days.    In  Vienna,  a 


Manion;  Some  European  Clinics. 

knowledge  of  German  is  needed  to  get  the  best  out 
of  the  work. 


At  the  Clinical  Congress  of  Surgeons  in  Chicago, 
in  November  last,  a  number  of  us  had  the  pleasure 
of  meeting  Professor  Kronig  of  Freiburg,  and  for 
this  reason,  as  well  as  for  the  fact  that  this  little 
German  city  stands  high  clinically,  it  was  a  great 
privilege  to  spend  a  couple  of  days  in  this  charming 
and  beautiful  spot.  From  the  hotel  the  directions 
of  the  concierge  were  quite  German :  "Follow  Bis- 
marckstrasse  till  you  come  to  Rheinstrasse,  and 
then  go  to  number  seven,  to  reach  the  hospital." 
Unfortunately,  Professor  Kronig  was  just  leaving 
for  his  Easter  holidays,  but  he  welcomed  his  visitor 
as  an  old  friend.  His  assistant.  Doctor  Haus- 
feldt,  demonstrated  some  of  their  work  to  me,  a 
great  deal  of  which  consists  in  thp  treatment  of 
cancer  (in  both  male  and  female  patients),  with 
radium,  mesothorium,  and  Rontgen  rays ;  they  think 
the  results  very  promising.  They  have  employed 
the  treatment  for  only  two  years,  but  are  very 
hopeful  for  the  future,  although  they  make  few 
positive  statements.  Frequently  they  operate  first, 
then  use  their  treatments.  The  hospital  is  the  uni- 
versity clinic,  and  the  buildings  are  quite  up  to  date. 
Professor  Kronig's  private  patients  occupy  a  large 
wing  of  the  building.  The  treatments  are  very 
costly,  and  Doctor  Kronig  jocularly  remarked  that 
at  times  it  is  necessary  to  watch  the  patients  when 
they  have  in  some  part  of  their  bodies  a  valuable 
tube  of  radium. 


